Reply: Preventing Tip Modifications and Alar Retractions: The “Joy-Ride” Stitch

Abstract

Sir: We would like to thank Dr. Lanfranchi and colleagues for their gracious comments regarding our article on preventing alar retraction by preservation of the lateral crus. He and his colleagues present a clear and concisely written description of preventing tip distortion and alar retraction by using a columellar strut that is sutured to the columellar septum. Their technique is clear and logical. The concept of columellar struts (placed between the middle/medial crura) is certainly not new. Dibbell1 was one of the original surgeons using it for cleft lip nose. Others2–16 have shared similar experiences, reinforcing the notion that a strut provides tip projection and symmetry and also, to some extent, prevents tip distortion that occurs with other techniques. Suturing the columellar strut to the caudal septum to stabilize the tip is also a good idea. The concept of securing the tip complex to the caudal septum began with Joseph himself and was later popularized by Daniel17 and others.18–20 Although not necessarily specified in publications, use of columellar struts supported with sutures to the septum has been reported anecdotally. However, Dr. Lanfranchi and colleagues appear to be among the first to publish results on the combination of these two maneuvers. We are not clear, however, on how the columellar strut–suture combination prevents alar retraction that can occur following excision of the cephalic part of the lateral crus. Cephalic migration of the lateral nasal wall is relatively independent of stabilization procedures to the columella and domes. Also, we have not noticed that columellar struts with columella septal sutures have obviated the need to protect alar retraction from occurring. To some extent, securing the tip (as the authors do) can indirectly stabilize the alar rim. However, the effect is minimal in our experience or we would not feel the need to preserve as much of the lateral crus as possible. However, we appreciate the authors' recognition of our small contribution. Ronald P. Gruber, M.D. A. Zang, M.D. K. Mohebali, M.D. University of California, San Francisco San Francisco, Calif. Stanford University Palo Alto, Calif.